• Assume expulsion until proved otherwise. Confirm the location of the intrauterine device (IUD) by history, clinical examination and, as necessary, by ultrasound and X-ray.
• Expelled IUD
• Arrange for the woman to resume regular contraception.
• Consider if emergency contraception is indicated. For further information, see the CKS topic on Contraception - emergency.
• Intrauterine IUD
• The options are conservative management (leaving the IUD where it is), or replacing it.
• Extrauterine IUD or IUD embedded in uterine wall
• Refer for specialist management.

In depth

• Exclude ectopic pregnancy and advise that the risk of miscarriage, infection, or preterm delivery is increased if the intrauterine device (IUD) is left in place.
• Advise that removal of the IUD is recommended, but there is a small risk of miscarriage.
• If the woman agrees to removal, it should be done as soon as possible and before 12 weeks of gestation.
• If the woman does not wish to continue with the pregnancy, the IUD can be removed at the time of abortion.

In depth

• Reassure the woman that menstrual irregularities (spotting, light bleeding, heavy and/or prolonged menstruation) are common in the first 3–6 months but usually subside.
• Consider prescribing mefenamic acid for spotting/light bleeding or tranexamic acid for heavy and/or prolonged bleeding.
• To prevent anaemia, provide an iron supplement and/or encourage consumption of foods containing iron.
• Exclude or manage other situations which could result in unscheduled bleeding, such as:
• Sexually transmitted infections.
• Risk of STI if the woman is under 25 years, or has a new sexual partner, or more than one partner in the last year.
• Misplaced device.
• Pregnancy.
• Gynaecological conditions such as endometrial polyps, endometrial cancer, cervical cancer, or other gynaecological abnormality.
• Speculum examination is warranted:
• For persistent bleeding beyond the first 3–6 months of use.
• For new symptoms or a change in bleeding after at least 3 months of use.
• If the woman has not participated in a National Cervical Screening programme.
• If requested by the woman.
• If there are other symptoms such as pain, dyspareunia, or post coital bleeding. (Note that these symptoms also warrant pelvic examination.)
• Refer if the cause of the bleeding cannot be determined or treated in primary care.

In depth

• Take a cervical swab to test for Chlamydia trachomatis and Neisseria gonorrhoeae, and treat with appropriate antibiotics.
• The device should be removed if the woman wishes removal or if symptoms have not resolved within 72 hours.
• If the device is going to be removed:
• Ask if the woman has had sexual intercourse within the last 7 days and consider offering emergency hormonal contraception. For more information see the CKS topic on Contraception - emergency.
• Review after treatment.

In depth

• Assess for symptoms of pelvic inflammatory disease:
• Symptomatic: consider investigation and treatment, or referral to specialist services; there is probably no need to remove the copper intrauterine device (IUD).
• Asymptomatic: leave IUD in place.

In depth